Long Beach Memorial In Search of Excellence: A Program, Protocols and Software For a Total Joint...

Long Beach Memorial

In Search of Excellence: A Program, Protocols and Software

For a Total Joint Center With Outcomes

Doug Garland, MD

Medical Director

October 2015

Long Beach MemorialWhat We’ll Cover

• How did Long Beach Memorial Joint Replacement Center move from two distinct levels of care?

• How are measurement, outcomes, and effective leadership used to change surgeons’ practices?

• What’s the latest in the JR literature and how does our study on surgeon volume and protocols enhance it?

Long Beach Memorial

Physician’s Disclosure Statement

I have no relevant financial or nonfinancial relationships in the outcomes, research, or services described, reviewed, evaluated or compared in this presentation. I have no financial arrangements with any medical companies to include : stocks, stock options, consulting fees or patents. 

~Dr. Douglas E. Garland

Long Beach MemorialWho We Are

Long Beach Memorial, Long Beach, CA –462 licensed beds –More than 20,000 discharges per year –More than 990 board-certified physicians providing expert care –One of the largest joint replacement centers in the west

Long Beach MemorialJoint Replacement at LBM

• Competitive analysis through 2012: Long Beach Memorial has a 27% market share, #1 amongst competitors.

• Long Beach performs more than 550 total joint replacements annually and continues to grow.

• Addition of MAKOplasty® Robotics has recruited additional surgeons.

Long Beach MemorialSo What is the Problem?

Two Levels of Care

“We cannot become what we need to be by remaining who we are.”

~Max DePree, Leadership Coach

Long Beach Memorial

Reasons for Surgeon Non-Performance

• “There are too many obstacles beyond my control.”

• “There’s no positive benefit for ME.”

• “Efficiency is more work.”

• “My way is better.”

• “It won’t work.”

Long Beach Memorial

“A captain of a large vessel with a large hole must learn to bail faster than the incoming water.”

~Douglas E. Garland

Long Beach MemorialLeadership

“Larger-than-life celebrity leaders who ride in from the outside are negatively correlated with taking a company from good to great.

10 of 11 ‘good to great’ CEOs came from inside the company, whereas the comparison companies tried outside CEOs six times more often.”

~Jim Collins, “Good to Great”

Long Beach Memorial5 Critical Reads

• The 7 Habits of Highly Effective People~Stephen Covey

• Good to Great ~Jim Collins

• In Search of Excellence ~Tom Peters

• Raving Fans ~Ken Blanchard

• The Peter Principle ~Lawrence J. Peter

Long Beach Memorial

Joint Replacement Center

• Program launched September 2009• Design based on Marshall Steele and Associates

research/recommendations• Offers a dedicated, multidisciplinary team

• Surgeon• Anesthesiologist• Joint Care Coordinator• Admissions Staff• Therapy Team (PT,OT)• Specially Trained Nursing• OR and PACU staff• Dietician

Long Beach Memorial

Joint Replacement Center at Long Beach Memorial

Our MissionReplacing arthritic joints with artificial joints using precision surgery with minimal complications in a wellness environment.

Launch

Long Beach MemorialJourney of the JRC

9/9/2009

PHASE I Launch

of the JRC1/1/2011

Dr. Douglas Garland AssumesJRC Medical Director

“Begin with the end in mind”

12/1/2010Dr. Douglas Jackson retires

as JRC Medical Director

11/16/2011

PHASE IIFocus on Rapid Rehab

(The whole is > than the sum of its parts)

2/26/2012

PHASE III Jill Roberston, PA hired

9/9/2013

Phase IVRecruitment and Robotics

12/5/2014MAKOplasty®

Robotics

Long Beach MemorialProgram Enhancements

7/18/2013First Outpatient

Total Hip

8/8/20111st Same-Day

Total Hip (Male)5/2/2012

Marketing Increases Promotion of JRC

4/24/20137 day “waves” for JRC

patient surgical process flow

(Jump on the Wave of Excellence)

9/9/2013First

Same-Day Total Joint (Female)

2/2/2011OR Conversion to

3 Total Joint Rooms Spinal Anesthesia Standard

12/9/2013First Same-Day

Total Knee

7/21/2014Diabetes Service

Joins JRC

1/1/2011Dr. Douglas Garland Assumes

JRC Medical Director “Begin with the end in mind”

Long Beach Memorial

Patient Experience: The whole is greater than the sum of its

parts Physician

•Pre-op class•Pre-admission

• MRSA and MSSA Screen•Nursing

• Out of bed most of day• Group lunches

•Therapies• Walk Day of Surgery• Twice Daily• Set Schedule• Group Sessions

Patient Experience

• Discuss options• Check Hg• Schedule Surgery• Schedule Pre-Op Class• Medical Clearance• Consent• Pre-Emptive Meds• Minimally Invasive Surgery

•OR• Anesthesia Tech• Dedicated Joint Team• Room Turnover Team

•PACU• Designated Space and

team•Anesthesia

• Multimodal• Pre-emptive meds

Hospital

Peri-operative Services

Patient Engagement•Pre-operative class

•Establish coach •Understand pain management•Feedback and reunion lunches

PATIENT EXPERIENCE

20%20%

20%

20%

100%

Long Beach MemorialPatient Spotlights

Long Beach MemorialJRC Program

Since Launch*•2301 hip/knee replacements •Went from 8 to 21 participating surgeons•37% increase in volume •2.18 day stay in hospital (reduction of .71 days)•Blood transfusion rate reduced from 33.3% to 5.7% estimating an overall savings of $582,818 •5.6% reduction in direct costs•Improved average margin by $2,831per patient (76% increase)•Standardized protocols for all team members•Incorporated best practice in anesthesia type selection

* Data summary from Marshall Steele Joint Replacement database from CY2010 through CY2014

Long Beach MemorialWhat We Measure

Long Beach Memorial

Select Key Metrics & Drilldown

Long Beach MemorialDrill Down Last 4 Quarters

Long Beach MemorialDrill Down by Surgeon

Long Beach MemorialData Yearly Since Launch

Blood Transfusion Rate

Long Beach MemorialReview of Literature

• Total Joint Arthroplasty is the single largest Medicare cost--$40.8 billing annually.1

• Higher volume surgeons (>50 surgeries annually) and hospitalswith >100 surgeries annually have better outcomes with fewer adverse events.2, 3

Long Beach MemorialReview of Literature

• 52% of primary THA are done by surgeons doing 10 or fewer cases/year (n=58,212)2

• THA Revision and dislocation rates increase in surgeons doing <12 cases/year (n=57,488)4

• Hospitals with >100 THA cases/year had less adverse events that hospitals with fewer than 25 cases/year.5

• Surgeon volume is the most important determinant of orthopedic complications.5

Long Beach MemorialReview of Literature

• Bozic (2010)– Surgeons in the lowest quartile for THA had

higher complication rates, readmission rates, re-operation rates, and longer hospital stays.6

Long Beach MemorialReview of Literature

• Katz: “However, the data we have suggests that experience and developing systematized approaches….can lead to better patient outcomes.” 7

Long Beach MemorialMeta-Analysis

Readmission Rates8

THA Readmission Rate

30 Days 5.6%

90 Days 7.7%

TKA Readmission Rate

30 Days 3.3%

90 Days 9.7%

Long Beach MemorialMeta-Analysis

Transfusion Rate Trends8

Long Beach MemorialReview of Current Study

In Search of Excellence: A Program, Protocols and Software

For a Total Joint Center With Outcomes

Long Beach MemorialBeginning with the End in Mind

• We agree with Katz to a point in that high volume surgeons and systematic approaches lead to better

outcomes….. BUT effective leader implementation and data collection with continuous review improves performance for all, especially for the low volume surgeons.

Sharpen the Saw (Stephen Covey’s 7th habit)

Long Beach MemorialMethods

• During the 2012 calendar year, data of key outcomes for all total hip and knee arthroplasty cases performed at a large community hospital were collected and analyzed.

• The cases were performed by two groups of surgeons: Those participating in the JRC program (Group I) and those who declined to participate in the program (Group II). – Further analysis divided Group I cases into those

performed by surgeons with greater or less than 50 annual cases

Long Beach Memorial

Methods – Measured Outcomes and Analysis

• Key outcomes measured included blood transfusion rate, complication rate, mortality rate, 30-day readmission rate, discharge location, and length of hospital stay.

• Statistics: These outcomes were compared across each of the groups.– For categorical data, a Chi-Squared Test was performed– For numerical data (length of stay), an independent samples t-test

was performed– Significance was determined by a p-value<0.05

Long Beach MemorialMaterials

• Group I (JRC Surgeons): 499 cases

–Group IA (JRC Surgeons with > 50 annual cases): 341 cases

–Group IB (JRC Surgeons with < 50 annual cases): 158 cases

• Group II (Non-JRC Surgeons): 96 cases

Non-JRC

JRC > 50 case

s

JRC < 50 case

s

Group I Group II

IA IB

Long Beach Memorial

Results: Blood Transfusion Rates

• Group I (JRC Surgeons) vs. Group II (Non-JRC Surgeons): 13.4%(67) vs. 52.1%(50) (p<0.001, SS)

• Group IA vs. Group IB: 10.0%(5) vs. 20.9%(20) (p<0.001, SS)

• Significantly less transfusions in Group IB vs. Group II (p<0.001, SS)

Lower volume JRC surgeons performed better than NON-JRC surgeons

Long Beach Memorial

Results: Discharge to Home

• Group I vs. Group II: 83.0%(439) vs. 53.1%(51) (p<0.001, SS)

• Group IA vs. Group IB: 88.6%(302) vs. 70.9%(112) (p<0.001, SS)

• Significantly more patients discharged to home in Group IB vs. Group II (p=0.004, SS)

Lower volume JRC surgeons performed better than NON-JRC surgeons

Long Beach Memorial

Results: Length of Stay

• Group I vs. Group II: 2.4 vs. 4.0 (p<0.001, SS)

• Group IA vs. Group IB: 2.3 vs. 2.6 (p=0.005, SS)

• Significantly more patients discharged to home in Group IB vs. Group II (p<0.001, SS)

Lower volume JRC surgeons performed better than NON-JRC surgeons

Long Beach Memorial

Results: Readmission Rate

• Group I vs. Group II: 3.2%(16) vs. 6.3%(6) (p=0.148, NS)

• Group IA vs. Group IB: 3.5%(12) vs. 2.5%(4) (p=0.560, NS)

Lower volume JRC surgeons performed better than NON-JRC surgeons

Long Beach MemorialResults: Complication Rate

• Group I vs. Group II: 0.60%(3) vs. 1.04%(1) (p=0.629, NS)

• Group IA vs. Group IB: 0.60%(1) vs. 0.60%(1) (p=0.950, NS)

Both JRC surgeon groups performed equally better than NON-JRC surgeons

In-house complications include: •UTI•SSI•Hematoma•DVT•PE

Long Beach MemorialResults: 30-day Mortality

• Group I vs. Group II: 0.20% (1)vs. 0% (p=0.661, NS)

• Group IA vs. Group IB: 0% vs. 0.60% (1) (p=0.141, NS)

1 Patient expired within 30 days post-surgery in JRC Group 1B

Long Beach MemorialConclusion

• Participation in JRC was the major determinant for positive patient outcomes

• Active/high volume JRC surgeons had the best outcomes.

• Low volume JRC surgeons far outperformed non-JRC surgeons.

• Low volume surgeons (who perform the majority of joint replacements in the U.S.) can significantly improve certain clinical outcomes and cost savings to the hospital by participating in a well-functioning JRC program.

Long Beach MemorialSummary

We agree with Katz to a point in that high volume surgeons and systematic approaches lead to better outcomes….. BUT effective leader implementation and data collection with continuous review improves performance for all, especially the low volume surgeons.

Sharpen the Saw - Stephen Covey’s 7th habit

Long Beach MemorialReferences

1. Bozic, KJ, Rubash HE, Sculco TOP, Berry DJ. An analysis of Medicare payment policy for total joint arthroplasty. J Arthroplasty.2008;23(6 suppl 1):133-138.

2. Katz JN, Losina E, Barrett J, Phillips CB, Mahomed NN, Lew RA, Guadagnoli E, Harris WH, Poss R, Baron JA. Association between hospital and surgeon procedure volume and outcomes of total hip replacement in the United States Medicare population. J Bone Joint Surg Am. 2001 Nov;83-A(11):1622-9.

3. Katz JN, Barrett J, Mahomed NN, Baron JA, Wright RJ, Losina E. Association between hospital and surgeon procedure volume and the outcomes of total knee replacement. J Bone Joint Surg Am. 2004 Sep;86-A(9):1909-16.

4. Losina E, Barrett J, Mahomed NN, Baron JA, Katz JN. Early failures of total hip replacement: effect of surgeon volume. Arthritis Rheum. 2004 Apr;50(4):1338-43.

5. Solomon DH, Losina E, Baron JA, Fossel AH, Guadagnoli E, Lingard EA, Miner A, Phillips CB, Katz JN. Contribution of hospital characteristics to the volume-outcome relationship: dislocation and infection following total hip replacement surgery. Arthritis Rheum. 2002 Sep;46(9):2436-44.

6. Bozic KJ1, Maselli J, Pekow PS, Lindenauer PK, Vail TP, Auerbach AD. The influence of procedure volumes and standardization of care on quality and efficiency in total joint replacement surgery. J Bone Joint Surg Am. 2010 Nov 17;92(16):2643-52. doi: 10.2106/JBJS.I.01477.

2. Protocols, techniques may help overcome effects of surgeon volume on THA outcomes. Orthopedics Today. 2014(November);p2.

• Prem N. Ramkumar, MBA, Christopher T. Chu, MD, Joshua D. Harris, MD, Aravind Athiviraham, MD, Melvyn A. Harrington, MD, Donna L. White, PhD, David H. Berger, MD, MHCM, Aanand D. Naik, MD, and Linda T. Li, MD. Causes and Rates of Unplanned Readmissions After Elective Primary Total Joint Arthroplasty: A Systematic Review and Meta-Analysis. Am J Orthop. 2015;44(9):397-405.

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Thank You